PassFinals
Trauma & Orthopaedics

Shoulder Dislocation

A traumatic glenohumeral dislocation is usually anterior after a fall onto an abducted, externally rotated arm; urgent controlled reduction depends on pre- and post-reduction neurovascular assessment and imaging, followed by rehabilitation and recurrence-risk review.

In a nutshell

A traumatic glenohumeral dislocation is usually anterior after a fall onto an abducted, externally rotated arm. The immediate priorities are two-view imaging, formal axillary-nerve and circulation checks before reduction, controlled reduction with adequate analgesia or sedation, and repeat imaging and examination afterwards.

Classic presentation

A patient with severe shoulder pain, a squared-off contour and an arm held in abduction and external rotation after a fall, with marked loss of movement.

Key points

  • Anterior dislocation is common after a fall onto an outstretched or abducted, externally rotated arm; posterior dislocation is a key trap after seizure or electrocution.
  • Document axillary-nerve sensation, deltoid function and distal pulses before and after reduction.
  • Obtain anteroposterior and axial, modified axial or scapular-lateral views before reduction when safe, and two post-reduction views.
  • Reduce in a controlled environment with adequate analgesia or sedation and a trained clinician; do not attempt self-reduction or forceful manoeuvres.
  • Use a sling for comfort and begin early rehabilitation rather than prolonged immobilisation; recurrence-risk assessment is part of treatment.
  • Persistent weakness in an older patient suggests rotator-cuff injury; recurrent instability or structural injury warrants shoulder-specialist review and shared decisions about surgery.

First-line investigation

Two-view shoulder radiographs with a documented neurovascular examination before reduction; repeat both after reduction.

Management

Support and assess

  • Support the arm, give analgesia using the current BNF and local trauma protocol, and document axillary-nerve and distal neurovascular status before manipulation.1,2,3

Image safely

  • Obtain two views before reduction when safe, using anteroposterior plus axial, modified axial or scapular-lateral imaging to confirm direction and associated fracture.1

Reduce and recheck

  • Perform controlled closed reduction with adequate analgesia or sedation; then obtain two post-reduction views and repeat the full neurological and circulatory examination.1,3

Rehabilitate early

  • Use a sling for comfort, keep the elbow, wrist and hand moving, and start shoulder rehabilitation as pain and the specialist plan allow; avoid prolonged immobilisation.1,2

Prevent recurrence and detect associated injury

  • Arrange follow-up to assess age- and activity-related recurrence risk, persistent weakness, labral or bony injury and the need for specialist imaging or stabilisation surgery through shared decision-making.1,2

Exam traps

  • A present pulse does not replace a complete axillary-nerve and distal neurovascular examination.
  • Posterior dislocation may be missed on an AP view; think of seizure or electrocution and obtain an appropriate second view.
  • Do not repeatedly or forcefully manipulate a fracture-dislocation or failed reduction: escalate to orthopaedics.
  • Older patients can have a clinically important traumatic rotator-cuff tear after reduction, especially with persistent weakness.
  • Relocation is not the end of care: start rehabilitation and assess recurrence risk, structural injury and the need for specialist stabilisation.

Illustrations

AP radiograph of an anterior shoulder dislocation: the humeral head lies antero-inferior to the glenoid (arrowed).Clinical photograph showing loss of the deltoid contour and the arm held in slight abduction and external rotation.James Heilman, MD, Wikimedia Commons · CC-BY-SA-4.0
Axillary nerve course around the surgical neck of the humerusDiagram of the axillary nerve wrapping around the surgical neck, explaining its vulnerability in anterior dislocation.PassFinals · original

Key sources

  1. BESS/BOA Patient Care Pathway: Traumatic anterior shoulder instability (UK shoulder pathway covering pre-hospital advice, two-view imaging, pre- and post-reduction neurovascular assessment, controlled reduction, cuff assessment, rehabilitation and recurrence-risk management; published in Shoulder & Elbow and hosted by BOA/BESS.)
  2. NHS: Dislocated shoulder (Current NHS advice on urgent assessment, avoiding self-reduction, reduction with analgesia or sedation, sling use, recovery and recurrence-risk follow-up.)
  3. BNF online: current analgesia and sedation prescribing information (Use the current BNF and local monitored-reduction protocol for age-, weight-, renal-function- and pregnancy-appropriate analgesia or sedation, contraindications and monitoring; no fixed dose is reproduced here.)

This page is exam revision material, not medical advice, and must not be used for patient care. Always check drug doses against the BNF and current guidance. Full disclaimer.